ICD-10 Coding for Pain on Urination(R30.0, N39.0)
Complete ICD-10-CM coding and documentation guide for Pain on Urination. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Pain on Urination
R30-R39Primary Range
Symptoms and signs involving the urinary system
This range includes codes for symptoms related to the urinary system, including dysuria.
Other diseases of the urinary system
This range includes codes for specific urinary system diseases, such as UTIs, which can cause dysuria.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R30.0 | Dysuria | Use when dysuria is present without a confirmed underlying condition. |
|
| N39.0 | Urinary tract infection, site not specified | Use as primary when UTI is confirmed. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for pain on urination
Essential facts and insights about Pain on Urination
Primary ICD-10-CM Codes for pain on urination
Decision Criteria
clinical Criteria
- Dysuria without confirmed infection.
coding Criteria
- No definitive diagnosis available.
Applicable To
- Painful urination
Excludes
- Urinary tract infection (N39.0)
Clinical Validation Requirements
- Patient reports burning sensation during urination.
- Urinalysis shows no infection.
Code-Specific Risks
- Incorrectly using as primary code when a definitive diagnosis exists.
Coding Notes
- Ensure dysuria is documented as a symptom when no definitive diagnosis is present.
N39.0 - Urinary tract infection, site not specified
Use as primary when UTI is confirmed.
Applicable To
- UTI
Excludes
- Dysuria (R30.0)
Clinical Validation Requirements
- Urine culture with ≥10⁵ CFU/mL of a single organism.
- Presence of symptoms such as fever or urgency.
Coding Notes
Ensure UTI is confirmed by lab results before coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Frequency of micturition
R35.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Pain on Urination to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R30.0.
Impact
Clinical: Potential misdiagnosis., Regulatory: Non-compliance with documentation standards., Financial: Risk of denied claims.
Mitigation Strategy
Ensure lab results are documented in the patient's record., Verify culture results before finalizing the diagnosis.
Impact
Reimbursement: Incorrect DRG assignment leading to lower reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use N39.0 as primary when UTI is confirmed by culture.
Impact
Using symptom codes as primary when a definitive diagnosis is available.
Mitigation Strategy
Review coding guidelines and ensure proper sequencing.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Pain on Urination, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Pain on Urination
Use these documentation templates to ensure complete and accurate documentation for Pain on Urination. These templates include all required elements for proper coding and billing.
Primary Care Visit for Dysuria
Specialty: Primary CareRequired Elements
- Patient history
- Symptom description
- Lab results
- Physical exam findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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